Superiority of urgent vs early endoscopic hemostasis in patients with upper gastrointestinal bleeding with high-risk stigmata

Acute Nonvariceal Upper Gastrointestinal Bleeding in Patients Using Anticoagulants: Does the Timing of Endoscopy Affect Outcomes?

BACKGROUND

In patients with acute nonvariceal upper gastrointestinal bleeding (NVUGIB), early (≤ 24 h) endoscopy is recommended following hemodynamic resuscitation. Nevertheless, scarce data exist on the optimal timing of endoscopy in patients with NVUGIB receiving anticoagulants.

OBJECTIVE

To analyze how the timing of endoscopy may influence outcomes in anticoagulants users admitted with NVUGIB.

METHODS

Retrospective cohort study which consecutively included all adult patients using anticoagulants presenting with NVUGIB between January 2011 and June 2020. Time from presentation to endoscopy was assessed and defined as early (≤ 24 h) and delayed (> 24 h). The outcomes considered were endoscopic or surgical treatment, length of hospital stay, intermediate/intensive care unit admission, recurrent bleeding, and 30-day mortality.

RESULTS

From 636 patients presenting with NVUGIB, 138 (21.7%) were taking anticoagulants. Vitamin K antagonists were the most frequent anticoagulants used (63.8%, n = 88). After adjusting for confounders, patients who underwent early endoscopy (59.4%, n = 82) received endoscopic therapy more frequently (OR 2.4; 95% CI 1.1-5.4; P = 0.034), had shorter length of hospital stay [7 (IQR 6) vs 9 (IQR 7) days, P = 0.042] and higher rate of intermediate/intensive care unit admission (OR 2.7; 95% CI 1.3 - 5.9; P = 0.010) than patients having delayed endoscopy. Surgical treatment, recurrent bleeding, and 30-day mortality did not differ significantly between groups.

CONCLUSION

Early endoscopy (≤ 24 h) in anticoagulant users admitted with acute nonvariceal upper gastrointestinal bleeding is associated with higher rate of endoscopic treatment, shorter hospital stay, and higher intermediate/intensive care unit admission. The timing of endoscopy did not influence the need for surgical intervention, recurrent bleeding, and 30-day mortality.

Three Simple Parameters on Admission to the Emergency Department are Predictors for Endoscopic Intervention in Patients with Suspected Nonvariceal Upper Gastrointestinal Bleeding

BACKGROUND

A considerable number of patients with nonvariceal upper gastrointestinal bleeding (UGIB) need endoscopic intervention.

OBJECTIVE

The aim of this study was to determine factors that predict the need for endoscopic intervention at the time of admission to the emergency department.

METHODS

Consecutive patients with International Classification of Diseases, Tenth Revision diagnosis code K92.2 (gastrointestinal hemorrhage) who underwent upper endoscopy between February 2019 and February 2022, including patients diagnosed with nonvariceal UGIB in the emergency department in the study were reviewed retrospectively. The patients were divided into two groups: those treated endoscopically and those not treated endoscopically. These two groups were compared according to clinical and laboratory findings at admission and independent predictors for endoscopic intervention were determined using multivariate regression analysis.

RESULTS

Although 123 patients (30.3%) were treated endoscopically, endoscopic treatment was not required in 283 (69.7%) patients. Syncope, mean arterial pressure (MAP), and blood urea nitrogen (BUN) at admission were independent predictors for endoscopic intervention in the multivariate analysis, after adjusting for endoscopy time. The area under the curve of the syncope+MAP+BUN combination for endoscopic intervention was 0.648 (95% CI 0.588-0.708). Although the syncope+MAP+BUN combination predicted the need for intervention significantly better than pre-endoscopy Rockall and AIMS65 scores (p = 0.010 and p < 0.001, respectively), there was no significant difference in its comparison with the Glasgow-Blatchford score (p = 0.103).

CONCLUSIONS

Syncope, MAP, and BUN at admission were independent predictors for endoscopic therapy in patients with nonvariceal UGIB. Rather than using complicated scores, it would be more practical and easier to predict the need for endoscopic intervention with these three simple parameters, which are included in the Glasgow-Blatchford score.

The Accuracy of Pre-Endoscopic Scores for Mortality Prediction in Patients with Upper GI Bleeding and No Endoscopy Performed

(1) Background: The assessment of mortality and rebleeding rate in upper gastrointestinal bleeding (UGIB) is essential, and several prognostic scores have been proposed. Some patients with UGIB did not undergo endoscopy, either because they refused the procedure, suffered from alcohol withdrawal symptoms or altered general status, or because the bleeding was severe enough to cause death before the endoscopy. The mortality risk in the subgroup of patients without endoscopy is poorly evaluated in the literature. (2) Methods: The purpose of the study was to identify the most useful scores for the assessment of in-hospital mortality in patients with UGIB with no endoscopy performed and no known etiology. A total of 198 patients with UGIB and no endoscopy performed were admitted between January 2017 and December 2021 and the accuracy of 12 prognostic scores and the Charlson comorbidity index for in-hospital mortality prediction were analyzed, as well as Child-Pugh Turcotte (CPT) and Meld scores in patients with cirrhosis. (3) Results: The mortality rate was 37.9%, higher than in variceal (21.9%, p < 0.0001) and non-variceal bleeding (7.4%, p < 0.0001). The most accurate scores by AUC were the International Bleeding score (INBS, 0.844), Glasgow Blatchford (0.783), MAP score (0.78), Iino (0.766), AIM65 and modified N-score (0.745 each), modified Glasgow-Blatchford (0.73), H3B2 and N-score (0.701); Rockall, Baylor, and T-score had an AUC below 0.7. MELD score was superior to CPT in patients with cirrhosis (AUC 0.811 versus 0.670). (4) Conclusions: The mortality rate in UGIB with no endoscopy was higher than in both variceal and non-variceal bleeding and was higher in the pandemic period but with no statistical significance (45.3% versus 32.14%, p = 0.0586), mainly because of positive cases. Only one case of rebleeding was noted; the hospitalization period was significantly shorter. The most accurate score was International Bleeding Score; the MELD score had a higher but moderate accuracy compared with CPT in patients with cirrhosis.